30th September 2016

Before HM Coroner Dr Andrew Harris
Southwark Coroners Court

An inquest jury today concluded that Richard Walsh, a prisoner with a history of depression who took his own life in HMP Belmarsh, should have been in a psychiatric hospital.

The jury found the cause of Richard’s death was suicide “with neglect constituted by the gross failure to provide basic medical care”.

Richard was 43 years old when he was found hanging in his cell on 19 July 2015. As well as being diagnosed with depression, he had a history of trying to take his own life and had previously been detained in a psychiatric hospital under the Mental Health Act. At the time of his death he had been confined alone in his cell for more than 23 hours per day, without time in the open air or any contact with other prisoners.

The jury found that Richard should have been detained in hospital and said: “It is more likely than not that if Mr Walsh had been detained in a hospital instead of Belmarsh he would not have killed himself.”

Specifically, the mental health practitioner and two psychiatrists who saw him at a police station after his arrest failed to:

  • Secure information about him from the custody record or custody officer, in particular about his delusional behaviour and obsession with a female police officer
    • Investigate the possibility of speaking with Richard’s relatives
    • Section Richard under the Mental Health Act

Richard Walsh’ mother, Linda Walsh, said:

“It has been heart-breaking to listen to some of the evidence which has come out during the inquest. Whilst I welcome the jury’s conclusions, to hear of the failings the jury have found which contributed to Richard’s death also makes me feel very sad. These conclusions will not bring Richard back, but more measures need to be put in place to try to stop this happening again. I hope that the jury’s conclusions, and any Prevention of Future Deaths report from the Coroner, will mean that action is taken which means no other family has to lose a son or daughter in similar circumstances.”

Deborah Coles, Director of INQUEST, said:

“Richard should never have been in prison in the first place, but in a secure psychiatric unit. The opportunity to safeguard him was lost by the failure to adequately assess him after his arrest. To put somebody with serious mental health issues in prison, in what amounts to solitary confinement for more than 23 hours a day, is nothing short of inhumane.”

Linda Walsh’s solicitor, Helen Stone of Hickman and Rose, said:

“The jury’s finding of neglect is a damning indictment of the way in which the Mental Health Act assessment was conducted on 26 June 2016. Evidence heard at the inquest was that had the assessment been carried out appropriately,  Richard Walsh should have been treated in a psychiatric hospital where he would have received medical care appropriate for his needs. Instead, Mr Walsh remained within the criminal justice system, and was ultimately able to take his own life in HMP Belmarsh.  It is clear that lessons need to be learned by all those involved in Mental Health Act assessments, especially in a police station setting, to ensure that those who should be in a psychiatric hospital get the treatment they need."

INQUEST has been working with Richard Walsh’s family since July 2015. Mrs Walsh is represented by INQUEST Lawyers Group members Helen Stone of Hickman and Rose and Richard Reynolds of Garden Court Chambers.

For further information please contact Laura Smith at INQUEST on 020 7263 1111.



Notes to editors:

Background to the case

  • After his arrest on 26 June 2015, Richard stated that he would all food and drink, an action that the custody officer believed this was his way of trying to end his life. An assessment under the Mental Health Act found that he was not suffering from a mental disorder serious enough for him to be moved to a psychiatric hospital and no follow up action was taken.
    • On 29 June, Richard was transferred to HMP Highdown where the nature of his alleged offence meant that he was categorised as a potential ‘Category A’ prisoner, meaning that he would be held in the segregation unit at Highdown until he was transferred to HMP Belmarsh.
    • After his transfer to Belmarsh on 2 July 2015, Richard expressed concerns for his safety due to the nature of his alleged offence and in response was placed on the ‘duty of care’ regime. This meant that he was on an ordinary prison wing but locked in his cell, alone, for 23.5 hours per day. He did not have time outside, the ability to mix with other prisoners or any purposeful activities.
    • On the night he took his own life, Mr Walsh was due, for security reasons, to be checked in his cell on four occasions by a member of prison staff.  None of these checks took place, despite the staff member recording that they had been done. The following morning Mr Walsh was found dead in his cell.
    • Two independent experts, Forensic Psychiatrist Professor Bob Peckitt, and Consultant Psychiatrist Dr Richard Latcham, told the inquest jury that they considered that Mr Walsh was suffering from a persistent delusional disorder and should have been detained in a psychiatric hospital.

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.